Pacemakers and implantable cardioverter defibrillators (or ICDs) are the heart rhythm “specialists” of the implantable cardiac device world. These “mini-computers” help to regulate dangerously abnormal heartbeats and arrhythmias like ventricular tachycardia and ventricular fibrillation. The rhythm-regulating electrical pulses of these devices are dependent on leads—thin, insulated wires less than two millimeters in diameter.
As important as this wiring is to these implantable devices and their functionality, it is sometimes necessary to undergo a lead extraction and replacement procedure. But do not worry! We will walk you through the lead extraction procedure, what you can expect in recovery, and why these little leads are such a big part of your device and, ultimately, your heart health.
Leads: The Connective Wiring of Pacemakers and ICDs
The heart is an electrical system, with the sinus node, located in the right upper chamber of the heart, generating an electrical stimulus that contracts the heart (about 60 to 100 times a minute). Each contraction is one heartbeat.
Leads are what connect pacemakers and ICDs to the heart’s electrical system. These wires carry electrical pulses from the device’s pulse generator to electrodes inside the heart chamber. In pacemakers, it is to regulate the rate and rhythm of the heartbeat. With ICDs, leads can also deliver shocks to the heart, cardioverting it with a mild shock or defibrillating it with a stronger shock to restore normal rhythm.
These devices can be wired to multiple chambers of the heart via multiple leads based on the type or severity of the arrhythmia or heart rhythm condition.
- Single-chamber Pacemaker and ICDs have a single lead going to one chamber of the heart, either the right atrium or the right ventricle.
- Dual-chamber Pacemaker and ICDs use two leads to connect to both the right atrium and the right ventricle to treat both chambers of the heart.
- Biventricular Pacemakers and ICDs use three leads: one in the right atrium, one in the right ventricle, and one in the left ventricle. These devices are most often used in patients suffering from heart failure, helping to synchronize or “resynchronize” contractions of the left and right ventricles.
What is Lead Extraction and Why Is It Necessary?
As you can see, leads are the critical wiring connecting your device to your heart. However, as time passes, there may be situations where these leads have to be removed and/or replaced via a lead extraction procedure.
Reasons for a lead extraction can include:
Infection
Device-related infection is the most common reason for lead extraction. This could be a localized infection near the device pocket or a more serious bloodstream infection like endocarditis. Infections pose a serious health risk, and removing the leads (and often the device itself) is essential for treatment.
Lead Malfunction
Leads can malfunction due to the wear and tear that comes with age. They can also break or be dislodged due to physical trauma. Damaged, broken, or malfunctioning leads can fail to deliver the electrical pulses from your device properly, causing a heart health risk.
Device Malfunction or Upgrades
Sometimes leads are removed if the device itself needs to be removed, like due to a malfunction or upgrade. Unfortunately, leads and their devices do not last forever. The average lifespan of a pacemaker is five to seven years and replacing your pacemaker with a newer or different device (e.g. replacing a pacemaker with an ICD) could also mean replacing the leads, rather than attaching the new device to the existing leads.
Health Issues or Complications
In some cases, leads may need to be removed due to health issues or complications. If a lead is causing blockages or scarring, removal and replacement may be necessary. The buildup of excessive scar tissue at the tip of a lead can create a block, slowing down the delivery of the electrical pulse, forcing the device’s pulse generator to work harder to produce more energy. If scar tissue or blood clot causes blockage of a vein a lead is in, this can necessitate lead extraction and the need for a different vein access for a new lead.
What Happens During a Lead Extraction Procedure?
Lead extraction is performed by experienced electrophysiologists in specialized centers equipped for this type of procedure. The complexity of lead extraction means the procedure is not without its risks. Infection (a risk with all surgical procedures), bleeding, vascular damage, and accidental tearing of the heart or blood vessels are some of the risks/side effects. This is a procedure in your cardiovascular system, so while rare, suffering a stroke, heart attack, and even death are possible. However, according to a study published in 2023, the procedural death rate was .08%, with a 98.3% clinical success rate per patient.
Understanding the steps of a lead extraction procedure can help alleviate the fears about these risks and make the procedure feel less daunting.
Steps of the Lead Extraction Procedure
- Pre-Procedure: Before the procedure is scheduled, you will likely undergo imaging tests like a chest X-ray, CT scan, or echocardiogram to help your medical team visualize the lead locations and plan the extraction.
- Incision: After going under general anesthesia, the doctor will make the incision. This will be a small incision either at the site of the implanted device (usually in the upper chest area) or groin area, depending on the location of lead(s) being extracted.
- Insertion: A sheath is inserted into the vein and guided by X-ray to reach the lead tip. Depending on the condition of the lead and the reason for the extraction, mechanical tools or laser sheaths (long tubes wrapped in laser optics) can be used. A laser sheath uses light energy to dissolve scar tissue, while a mechanical sheath functions more like a drill to free the lead from scar tissue that has formed around it.
- Lead Extraction: With the scar tissue cleared and the lead dislodged from the heart muscle, it is gently pulled out of the vein. This is then repeated based on the number of leads being extracted. New leads may be implanted at this time, for an extraction and replacement procedure, or in a second procedure.
The lead extraction procedure should take two to four hours, depending on the complexity and number of leads being removed and/or replaced.
What is the Recovery Process After Lead Extraction?
Once the procedure is over, the recovery begins. The recovery time and restrictions can be similar to your initial ICD or pacemaker implantation recovery. Here is what to expect in each stage of your recovery:
The First 24 Hours
Post-surgery, you will be moved to a recovery area where you will be monitored for any signs of complications. Most patients spend at least one night in the hospital for observation. Discomfort around the incision site is to be expected, and you will be given medication for pain management. You will most likely undergo an imaging test to verify device and lead placement and functionality, check for complications and ensure there is no bleeding.
Recovering at Home
Before being discharged from the hospital, your medical team will give you instructions on incision care, pain medications, physical restrictions, and scheduling follow-up appointments.
- Incision Care: Keep the incision area clean and dry, so do not put any powder, lotion, rubbing alcohol, or antiseptic solutions on the incision. The sterile strips and stitches over your incision should be dissolvable and will not need to be removed.
- Pain Medication: You should have received a prescription for pain medication at discharge. If not or you do not feel comfortable taking prescription pain medications, you can take an over-the-counter pain reliever. Acetaminophen (or Tylenol) is considered the safer over-the-counter pain reliever for people with heart conditions.
- Physical Restrictions: You should be safe to drive within seven to 10 days after your procedure. Avoid strenuous activities, high-intensity exercises, and heavy lifting (anything over 10 pounds) for the first four to six weeks.
- Follow-Up Visits: Your doctor may schedule a one-week checkup (either in person or via telehealth) to ensure your incision is healing properly and you are not experiencing any complications. You will then schedule your next post-op follow-up visit to ensure continued healing and to monitor your heart health
Find Support in the Pacemaker Club
Facing a lead extraction procedure can be intimidating, but with advancements in cardiac care and pacemaker lead technology, the procedure is both safe and highly successful. As cardiac care continues to progress, many providers are moving toward leadless pacemakers, an option that eliminates the need for traditional leads.
Want to learn more about lead extraction? Tap into additional resources and information through the Pacemaker Club, an online community where you can connect with pacemaker recipients and experts to ask questions, share experiences, and support one another as you navigate all the ins and outs (including lead extraction) of living with a pacemaker.